SULPHURIC ETHER, OR ETHER.
History and Composition. “This liquid is first described by Valerius Cordus, in 1540, under the name of oleum vitrioli dulce. The term ether was applied to it a hundred and ninety years afterwards by Frobenius, who, in a paper in the Philosophical Transactions, described its singular properties; at the end of this paper is a note by Godfrey Hankwitz, Mr. Boyle’s operator, mentioning the experiments that had been made upon it by Boyle and by Newton.”[[158]]
The present chemical name of ether, or sulphuric ether, is oxide of ethyle. It consists of four atoms carbon, five atoms hydrogen, and one atom oxygen. Its atomic number is consequently 37.
The usual way of making ether, is to distil common alcohol (the hydrated oxide of ethyle) with sulphuric acid.
Chemical and physical Properties. Ether is a clear, colourless liquid, of the specific gravity of 0·715 at 68°. It boils at 96° Fahr.; and the specific gravity of its vapour is 2·565. It is soluble, in all proportions, in alcohol, and it is soluble in nine parts, by measure, of water. Water is also soluble in nine parts, by measure, of ether, so that after ether has been agitated with water, it retains one-tenth of its volume of that fluid. Ether is very inflammable, and, as it yields its vapour very freely, great care is required in pouring it out by artificial light. Its vapour is also very explosive when mixed, in certain proportions, with atmospheric air.
The ordinary ether of the shops contains a portion of alcohol which has distilled over with it; the alcohol should be removed by agitating the ether with twice its volume of water, before it is used for inhalation. The ether which has been treated in this way is called washed ether. The water which it takes up during the washing can be removed by distilling it from lime, or dry carbonate of potassa; but this is unnecessary, as the water does not interfere with the action of the ether when inhaled; and part of the water evaporates and is inhaled with the ether, when the atmospheric air is not already saturated with moisture.
Ether has a peculiar and very strong odour; in this respect it differs extremely from chloroform. The odour of a single drop of ether can be distinctly perceived all over a large operating theatre, whilst a pint of chloroform may be spilt without its odour being much noticed. The strong odour of ether is, indeed, one of the greatest objections to its use, since another agent has been discovered which is free from this objection. As was previously stated, the odour of chloroform cannot be perceived in the breath, after the lungs are emptied by one or two expirations of the vapour just taken in; whilst the smell of ether can be perceived in the breath for twenty-four, and sometimes for forty-eight, hours after the patient has inhaled it. The surgeon, and others who have been about the patient, also smell of the ether to a less degree. When a rabbit has been killed by the inhalation of ether, a starving cat will not eat its flesh even after it has been boiled; whereas the odour of chloroform cannot be perceived in the bodies of animals that have been killed by it.
If ether is exposed to atmospheric air by being kept a long time in a bottle but partly filled, it is apt to be decomposed into acetic acid and water.
The following Table shows the result of experiments which I made to ascertain the quantity of vapour of ether that 100 cubic inches of air will take up, when saturated with it, at various temperatures, the barometric pressure being 30 inches of mercury. The ether I employed in the experiments was washed, but not dried. It was, therefore, saturated with water, of which it contained one-tenth of its volume. It had a specific gravity of 0·735 at 60° Fahr., and it boiled at 98°.
| Temp. Fah. | Cubic inches of vapour. | Minims of ether. |
|---|---|---|
| 50° | 52 | 64 |
| 51 | 54 | 66 |
| 52 | 56 | 69 |
| 53 | 59 | 72 |
| 54 | 62 | 76 |
| 55 | 65 | 80 |
| 56 | 68 | 84 |
| 57 | 72 | 88 |
| 58 | 76 | 93 |
| 59 | 80 | 98 |
| 60 | 84 | 102 |
| 61 | 88 | 107 |
| 62 | 92 | 112 |
| 63 | 97 | 117 |
| 64 | 102 | 122 |
| 65 | 107 | 128 |
| 66 | 112 | 134 |
| 67 | 117 | 140 |
| 68 | 123 | 147 |
| 69 | 130 | 156 |
| 70 | 138 | 165 |
In the above Table the air is a constant quantity of 100 cubic inches, which becomes expanded to 152, and so on; but the following Table shows the quantity of vapour in 100 cubic inches of the saturated mixture of vapour and air at different temperatures:—
| Temp. Fah. | Air. | Vapour. |
|---|---|---|
| 40° | 73 | 27 |
| 42 | 72 | 28 |
| 44 | 70 | 30 |
| 46 | 69 | 31 |
| 48 | 67 | 33 |
| 50 | 66 | 34 |
| 52 | 64 | 36 |
| 54 | 62 | 38 |
| 56 | 60 | 40 |
| 58 | 57 | 43 |
| 60 | 54 | 46 |
| 62 | 52 | 48 |
| 64 | 49 | 51 |
| 66 | 47 | 53 |
| 68 | 45 | 55 |
| 70 | 42 | 58 |
| 72 | 40 | 60 |
| 74 | 37 | 63 |
| 76 | 34 | 66 |
| 78 | 32 | 68 |
| 80 | 29 | 71 |
The absorption of caloric during the evaporation of ether is much greater than during that of chloroform, owing both to the greater quantity of vapour it yields on account of its lower boiling point, and to the lower specific gravity of the vapour. The evaporation of ether from the bulb of a thermometer usually lowers the temperature nearly to zero of Fahrenheit. When the inhalation of ether was first commenced, the inhalers employed consisted generally of glass vases containing sponge, to afford a surface for the evaporation of the ether. Both glass and sponge being very indifferent conductors of caloric, the interior of the inhalers became much reduced in temperature, the evaporation of ether was very much checked, and the patient breathed air much colder than the freezing point of water, and containing very little of the vapour of ether. On this account, and through other defects in the inhalers, the patient was often very long in becoming insensible, and, in not a few cases, he did not become affected beyond a degree of excitement and inebriety.
To ensure the ether taking effect in a short time in every case, I made use of the conducting power of the metals, and the great capacity of water for caloric. The inhaler which I employed was made of plated copper, and was placed in two or three pints of water, of the ordinary temperature. The form of the inhaler was that of one which had been contrived by Mr. Julius Jeffries for the inhalation of aqueous vapour.[[159]] No sponge or bibulous paper, or other material, was used; and the air, before being inhaled, was made to pass over a considerable surface of ether by means of a spiral volute, soldered to the top of the inhaler, and reaching nearly to the bottom. The accompanying engraving shows the interior of the inhaler, on a scale of half the dimensions, the bottom being removed.
The Physiological Effects of Ether are essentially the same as those of chloroform. The various degrees of narcotism which I described in the earlier part of this work, when treating of chloroform, were first described by me when treating of ether in 1847, before chloroform was in use.[[160]] All the remarks which I made with respect to the manner in which age, strength or debility, and other circumstances, influence the action of chloroform, apply also in an equal degree to ether.
I performed some experiments in 1848,[[161]] for ascertaining the proportions of vapour of ether present in the blood in the different degrees of narcotism. They were conducted on the same principles as those previously related, which were performed for the purpose of determining the same point in regard to chloroform.
Experiment 31. Two grains of ether were put into a jar holding 200 cubic inches, and the vapour diffused equally, when a tame mouse was introduced, and allowed to remain a quarter of an hour, but it was not appreciably affected.
Experiment 32. Another mouse was placed in the same jar, with three grains of ether, being a grain and a half to each 100 cubic inches. In a minute and a half, it was unable to stand, but continued to move its limbs occasionally. It remained eight minutes without becoming further affected. When taken out, it was sensible to pinching, but fell over on its side in attempting to walk. In a minute and a half, the effect of the ether appeared to have gone off entirely.
Experiment 33. A white mouse in the same jar, with four grains of ether, was unable to stand at the end of a minute, and at the end of another minute ceased to move, but continued to breathe naturally, and was taken out at the end of five minutes. It moved on being pinched, began to attempt to walk at the end of a minute, and in two minutes more seemed quite recovered.
Experiment 34. Five grains of ether, being two and a half grains to each 100 cubic inches, were diffused throughout the same jar, and a mouse put in. It became rather more quickly insensible than the one in the last experiment. It was allowed to remain eight minutes. It moved its foot a very little when pinched, and recovered in the course of four minutes.
Experiment 35. A white mouse was placed in the same jar with six grains of ether. In a minute and a half, it was lying insensible. At the end of three minutes, the breathing became laborious, and accompanied by a kind of stertor. It continued in this state till taken out, at the end of seven minutes, when it was found to be totally insensible to pinching. The breathing improved at the end of a minute; it began to move at the end of three minutes; and five minutes after its removal, it had recovered.
Experiment 36. The same mouse was put into this jar on the following day, with seven grains of ether, being 3·5 grains to the 100 cubic inches. Stertorous breathing came on sooner than before; it seemed at the point of death when four minutes had elapsed; and being then taken out, was longer in recovering than after the last experiment.
Experiment 37. Two or three days afterwards, the same mouse was placed in the jar, with eight grains of ether, being four grains for each 100 cubic inches. It became insensible in half a minute. In two minutes and a half, the breathing became difficult; and at a little more than three minutes, it appeared that the breathing was about to cease, and the mouse was taken out. In a minute or two, the breathing improved; and in the course of five minutes from its removal, it had recovered.
The temperature of the mice employed in the above experiments was about 100°. That of the birds in the following experiments was higher, as is stated; and they differ widely from the mice in the strength of vapour required to produce a given effect, although I found but little difference between the mice and birds, in this respect, in the former experiments on chloroform. And one of the linnets was employed in both sets of experiments. Having seen MM. Dumeril and Demarquay’s statement of the diminution of animal temperature from inhalation of ether and chloroform, before the following experiments were performed, the thermometer was applied at the beginning and conclusion of some of them. I have selected every fourth experiment from a larger series on birds.
Experiment 38. 18·4 grains of ether were diffused through a jar holding 920 cubic inches, being two grains to each 100 cubic inches, and a green linnet was introduced. After two or three minutes it staggered somewhat, and in a few minutes more appeared so drowsy, that it had a difficulty in holding up its head. It was taken out at the end of a quarter of an hour, quite sensible, and in a minute or two, was able to get on its perch. The temperature under the wing was 110° before the experiment began, and the same at the conclusion.
Experiment 39. Another linnet was placed in the same jar, with four grains of ether to each 100 cubic inches of air. In two minutes it was unable to stand, and in a minute more, voluntary motion had ceased. It lay breathing quietly till taken out, at the end of a quarter of an hour. It moved its foot slightly when it was pinched. In three minutes it began to recover voluntary motion, and was soon well. The temperature was 110° under the wing, when put into the jar, and 105° when taken out.
Experiment 40. A green linnet was put into the same jar with 55·2 grains of ether, being six grains to 100 cubic inches. It was insensible in a minute and a half, and lay motionless, breathing naturally, till taken out at the end of a quarter of an hour. It moved its toes very slightly when they were pinched with the forceps, and it began to recover voluntary motion in two or three minutes. Temperature 110° before the experiment, and 102° at the end.
Experiment 41. A linnet was placed in the same jar, containing eight grains of ether to each 100 cubic inches. Voluntary motion ceased at the end of a minute. The breathing was natural for some time, but afterwards became feeble, and at the end of four minutes appeared to have ceased; and the bird was taken out, when it was found to be breathing very gently. It was totally insensible to pinching. The breathing improved, and it recovered in four minutes.
Experiment 42. 9·2 grains of ether, being one grain to each 100 cubic inches of air, were diffused through the jar, holding 920 cubic inches of air, and a frog was introduced. At the end of a quarter of an hour, it had ceased to move spontaneously, but could be made to move its limbs, by inclining the jar so as to turn it over. At the end of half an hour, voluntary motion could no longer be excited, and the breathing was slow. It was removed, at the end of three-quarters of an hour, quite insensible, and the respiratory movements being performed only at long intervals, but the heart beating naturally; and it recovered in the course of half an hour. The temperature of the room was 55° at the time of this experiment.
We find from the 32nd experiment, that a grain and a half of ether for each 100 cubic inches of air, is sufficient to induce the second degree of narcotism in the mouse; and a grain and a half of ether make 1·9 cubic inch of vapour, of specific gravity 2·586. Now the ether I employed boiled at 96°. At this temperature, consequently, its vapour would exclude the air entirely; and ether vapour, in contact with the liquid giving it off, could only be raised to 100° by such a pressure as would cause the boiling point of the ether to rise to that temperature. That pressure would be equal to 32·4 inches of mercury, or 2·4 inches above the usual barometrical pressure; and the vapour would be condensed somewhat, so that the space of 100 cubic inches would contain what would be equivalent to 108 cubic inches at the usual pressure. This is the quantity, then, with which we have to compare 1·9 cubic inch, in order to ascertain the degree of saturation of the space in the air-cells of the lungs, and also of the blood; and by calculation, as when treating of chloroform,
1·9 is to 108 as 0·0175 is to 1.
So that we find 0·0175, or 1–57th to be the amount of saturation of the blood by ether necessary to produce the second degree of narcotism; and as by Experiment 35, three grains in 100 cubic inches produced the fourth degree of narcotism, we get 0·035, or 1–28th, as the amount of saturation of the blood in this degree. Now this is within the smallest fraction of what was found to be the extent of saturation of the blood by chloroform, requisite to produce narcotism to the same degrees. But the respective amount of the two medicines in the blood differs widely; for whilst chloroform required about 288 parts of serum to dissolve it, I find that 100 parts of serum dissolve five parts of ether at 100°; consequently 0·05 × 0·0175 gives 0·000875, or one part in 1142, as the proportion in the blood in the second degree of narcotism; and 0·05 × 0·035 gives 0·00175, or one part in 572, as the proportion in the fourth degree.
In Experiment 42 the frog was rendered completely insensible by vapour of a strength which was not sufficient to produce any appreciable effect on the mouse in Experiment 31. This is in accordance with what was met with in the experiments with chloroform. Air, when saturated with ether at 55°, contains 32 grains in each 100 cubic inches; so that the blood of the frog might contain 1–32nd part as much as it would dissolve, which, although not quite so great a proportion as was considered the average for the fourth degree of narcotism in the mice, yet was more than sufficient to render insensible the mouse in Experiment 34.
There is a remarkable difference between the birds and the mice, in respect to the proportions of ether and air required to render them insensible, a difference that was not observed with respect to chloroform. In some experiments with ether on guineapigs, which are not adduced, they were found to agree with mice in the effects of various quantities.
The birds were found to require nearly twice as much; five grains to 100 cubic inches, the quantity used in an experiment between the thirty-ninth and fortieth, which is not related, may be taken as the average for the fourth degree of narcotism in these birds, with a temperature of 110°. By the kind of calculation made before, we should get a higher amount of saturation of the blood than for the same degree in mice. But as serum at 110° dissolves much less ether than at 100°, the quantity of this medicine in the blood of birds is not greater than in that of other animals; and, considered in relation to what the blood would dissolve at 100°, the degree of saturation is the same.
By Experiments 36, 37, and 41, we find that with ether, as with chloroform, a quantity of vapour in the air, somewhat greater than suffices to induce complete narcotism, has the effect of arresting the respiratory movements.
In treating of chloroform (page 74), the average quantity of serum in the adult human subject was estimated at 410 fluidounces. In order to find the quantity of ether in the system, we may multiply 410 by 0·000875 for the second degree of narcotism, and by 0·00175 for the fourth degree, when we shall obtain 0·358 and 0·71 of an ounce, i. e. f. ʒii. ♏︎l in the first instance, and f. ʒv. ♏︎xl in the second. In the third degree of narcotism, in which surgical operations are usually performed, the quantity is intermediate, or a little over four drachms.
On the Administration of Ether. About a fluid ounce of ether is usually inhaled by an adult patient in becoming insensible; fully one-half of this is, however, thrown back from the lungs, windpipe, nostrils, and face-piece, without being absorbed. I usually put two fluid ounces of ether into the inhaler above described, at the beginning of the inhalation, and this quantity often lasts to the end of the operation, if it is not a protracted one. The inhaler is connected, by means of a wide elastic tube, with a face-piece similar to that described and delineated in treating of chloroform. It is necessary that the inhalation should commence, as in the case of chloroform, with the expiratory valve of the face-piece turned on one side, for the admission of air which is not charged with ether, and that the vapour should be admitted to the air-passages by degrees, to avoid the irritation that would arise from suddenly inspiring any considerable quantity of the vapour. The vapour of ether is very much less pungent than an equal quantity of the vapour of chloroform; but as the patient requires to breathe about six times as much of it in the inspired air, it feels quite as pungent as that of chloroform, and, perhaps, a little more so. Whilst the patient never requires to take in more than four or five per cent. of vapour of chloroform in the inspired air, he requires to inhale about thirty per cent. of vapour of ether, in order to be rendered insensible in a convenient time. The air-passages, however, soon get accustomed to the presence of the vapour of ether, and in a minute and a half or two minutes after the patient begins to inhale, he can usually bear the valve to be closed so far as to charge the air with as much vapour as is necessary speedily to cause insensibility. The inhaler yields quite sufficient vapour when the water-bath is at 50° Fahr.; and at the seasons of the year when the temperature of the water is higher, the expiratory valve of the face-piece can be left more or less open to admit a portion of air which has not passed through the inhaler.
I prefer the flavour of ether vapour to that of chloroform; and the sensations I experience from the inhalation of ether are more pleasurable than those from chloroform. Many persons agree with me on both those points; but some prefer chloroform. The quantity of ether expended in causing insensibility is eight or ten times as great as that of chloroform, but the quantity used in a protracted operation is not so disproportionate; for, owing to the great solubility of ether and the large quantity of it which is absorbed, it is much longer in exhaling by the breath, and when the patient is once fairly insensible, it does not require to be repeated so frequently as chloroform.
In administering ether, I usually rendered adult patients insensible in four or five minutes, and children in two or three minutes. A somewhat longer time was occasionally occupied in cases in which the air-passages were irritable, or where there was much rigidity and struggling. I never failed to make the patient insensible in any one instance in which I administered ether. I have notes of 152 cases in which I administered ether, before chloroform was introduced, and twelve cases in which I have exhibited it since.
Nearly all the great operations of surgery were included several times amongst the cases in which I administered ether. Amputation of the thigh was performed in nineteen cases; fifteen of the patients recovered, and four died. Amputation of the leg was performed eleven times; eight of the patients recovered, and three died. The arm was amputated three times; one of the patients died, and two recovered. There were thus thirty-three of the larger amputations with eight deaths, being a mortality of twenty-four per cent. There were two amputations of the forearm, and both patients recovered. There were nine operations of lithotomy; seven of the patients recovered, and two died. Five of the patients were children, who all recovered; the two deaths occurring amongst the four adult patients. Eighteen female patients had the breast removed for tumour, and they all recovered except one.
On July 1st, 1847, Mr. Cutler amputated the leg of a man, aged forty-four, in St. George’s Hospital, who had suffered from disease of the tibia and ankle, which had existed thirty years, and was caused by an accident. This patient died on the seventh day, of sloughing phagedena, which was present in the hospital. It was then found that he had disease of the heart. Its structure was soft and easily lacerable; much fat was mixed up with the muscular structure. The aortic valves were much thickened, and almost cartilaginous in structure. Two of them were so much contracted that they were together about the size of a healthy one. The left ventricle was dilated, and the right ventricle still more so; its walls being extremely thin. The ether had acted quite favourably on this man.
I administered ether repeatedly in infants and old people. Some of the infants were operated on by Mr. George Pollock, in 1847, for congenital cataract by drilling; and two of them were operated on, in 1857, for hare-lip, by Mr. Fergusson and Mr. Bowman. A gentleman, one of whose toes the late Mr. Liston amputated in 1847, was said to be subject to apoplectic attacks. The ether acted very favourably. Amongst the operations which Mr. Liston performed on patients to whom I administered ether, was the tying of the external iliac artery in a man, aged forty, for an aneurism of the groin, situated partly above Poupart’s ligament. The patient lay perfectly still in this, as in all the other important operations in which I administered ether. He recovered.
On June 18th, 1847, I exhibited, in University College Hospital, ether to a man, aged forty-two, with stricture of the urethra, caused by an accident. He passed his urine only in drops, and the attempts to pass a catheter had all failed. It was Mr. Liston’s intention to divide the urethra in the perinæum, but when the patient was placed fully under the influence of ether to the fourth degree of narcotism, a catheter (No. 1) passed into the bladder, and the operation was not required. Larger catheters were introduced in a few days, and on July 27th, the patient was discharged, being able to pass his urine in a good stream.
Ether was administered in many cases of midwifery by Dr. Simpson, who had first applied it in obstetric cases, and by a number of other practitioners. I only exhibited it in one case, and then only for a short time. Mr. Lansdown of Bristol used it in thirty cases.[[162]] In one case, it was continued for eleven hours and a half, and fourteen fluid ounces of ether were used. He said that he invariably found the perinæum relaxed before the head came to bear on it, thereby not requiring the pressure of the head to force it open, in cases where ether was used. He says: “I find the uterus sending out the placenta immediately after the expulsion of the child, and there has been scarcely any hæmorrhage following.” Mr. Lansdown said that he had found the action of the uterus to be induced by ether, when in a sluggish state, but he had not found this effect from chloroform, in the cases in which he had used it.
Ether was used with great advantage in most of the kinds of medical cases in which chloroform was afterwards applied. In the summer of 1847, an infant, nine months old, was brought to me in a convulsive fit, which had lasted twenty minutes. I poured twenty minims of ether on a sponge, and applied it to its mouth and nostrils; in two or three minutes, the quantity was repeated. The spasm subsided, and the child fell asleep. It had no return of the fit. It was labouring under hooping-cough at the time, which had existed a week.
The inhalation of ether was employed in the treatment of asthma, hooping-cough, and tetanus, before it was employed in surgical operations. It has been already stated (page 14) that Dr. Richard Pearson administered the vapour of ether in consumption in 1795. Dr. Robert Willis sent an article to the Medical Gazette on February 2nd, 1847,[[163]] in which the following passages occur.
“Ether, given by the mouth, has long been familiarly employed in the treatment of asthma. I have for many years been aware of the fact that it is vastly more efficacious administered directly in vapour by the breath. My plan of using it is extremely simple. I have had recourse to no kind of apparatus for this purpose, but have been content to pour two, three, or four drachms of the fluid upon a clean handkerchief, and to direct this to be held closely to the mouth and nostrils: a single short and difficult inspiration is hardly made before the effect is experienced; and I have occasionally seen the paroxysm ended in six or eight minutes, the respiration having in that brief interval become almost natural.
“It is not otherwise with hooping-cough: the paroxysms of coughing are positively cut short by having the ether and the handkerchief in readiness, and using them when the fit is perceived to be coming on.”
I have been informed of a case of tetanus which was treated successfully by inhalation of ether more than twenty years before this medicine was used to prevent the pain of operations, but I am not able at present to give a reference to the case. Mr. C. A. Hawkesworth, surgeon, of Burton-on-Trent, wrote me an account of a case of tetanus, which had recovered under the inhalation of ether in 1847. The patient was a healthy-looking butcher’s boy, about twelve years old, who had received a slight scalp wound, which was followed by general tetanus. Mr. Hawkesworth administered the vapour of ether to him during the greater part of one day. The spasm relaxed most completely whilst the influence of the ether continued, but returned in great degree when the inhalation was intermitted. He took no other medicine except calomel and jalap, with a view to purgation; the calomel, however, acted on his mouth. He recovered speedily and completely. Some other cases of recovery from tetanus under the inhalation of ether have been recorded in the medical journals.
In February, 1847, Dr. Sibson related several cases of facial neuralgia that had been greatly benefited by the inhalation of ether;[[164]] and it has been used in many cases since.
The inhalation of ether causes an increased flow of saliva in many cases; quite as frequently, in fact, as chloroform. Vomiting also follows the use of ether quite as often as that of chloroform. The insensibility from ether lasts longer than that from chloroform without repeating the inhalation when the narcotism is carried to the same degree. When the narcotism from ether is carried to the fourth degree there is generally a complete absence of pain for three minutes, and a state of unconsciousness for five minutes longer, a period during which any pain there might be would not be remembered afterwards. On account of this longer duration of the effects of ether, it is better adapted than chloroform for certain operations on the face, as removal of tumours of the jaws, the operation for hare-lip, and making a new nose. The relaxation of the muscular system from the effects of ether seems greater in general than from chloroform, and ether therefore seems to be the better agent to employ in the reduction of old dislocations, and strangulated hernia.
Great safety of Ether. I believe that ether is altogether incapable of causing the sudden death by paralysis of the heart, which has caused the accidents which have happened during the administration of chloroform. I have not been able to kill an animal in that manner with ether, even when I have made it boil, and administered the vapour almost pure. The heart has continued to beat after the natural breathing has ceased, even when the vapour has been exhibited without air; and in all cases in which animals have been made to breathe air saturated with ether vapour, at the ordinary temperatures of this country, they have always recovered if they were withdrawn from the vapour before the breathing ceased. Even in cases where the natural breathing had ceased, if the animal made a gasping inspiration after its removal from the ether it recovered.
I hold it, therefore, to be almost impossible that a death from this agent can occur in the hands of a medical man who is applying it with ordinary intelligence and attention.
I am only aware of two deaths which have been recorded as occurring during the administration of ether, and it is not probable that the death in either case was due to the ether. The first of these cases occurred in France, at the Hotel Dieu d’Auxerre, on July 10th, 1847.[[165]] The patient was a man fifty-five years of age, who had a cancerous tumour of the left breast of seven months duration. He was robust, and had no general lesion resulting from the cancerous disease. The ether was exhibited with the apparatus of Charrière. The patient had hardly inhaled two or three minutes when he became strongly excited. The trunk and limbs were agitated with violent starts and shocks. The breathing became frequent, and the face injected. He endeavoured to push away the inhaler, and babbled as if drunk. This state lasted for five minutes, and the prick of a pin showed that sensibility still remained. The apparatus was still applied, but in opening to the ether vapour an issue as large as the instrument permitted; for the tap which gave passage to it had hitherto been but half turned, and that progressively. At the end of ten minutes from the beginning of inhalation, the relaxation and immobility of the limbs was complete, the insensibility was not doubtful, the respiration was deep, gentle, but free from râle. The muscles of the face had ceased to be agitated, and it was of a violet red colour, as was also the skin in front of the chest; the pupils were turned upwards, dilated and immovable.
The apparatus was taken away, and the operation was commenced; but the incision had only given issue to a small quantity of black blood, when it was perceived that the features were altered and become entirely violet, and that the respiration was extremely feeble. The pulse, touched on this moment for the first time, was soft, full, and very slow. All at once it ceased to beat.
Twenty-four hours after death, all parts of the body yielded a strong odour of ether. The blood was deep black, fluid, and rather viscous. The blood which gorged the back part of the lungs had a consistence and colour somewhat like treacle. The mucous membrane of the bronchi, trachea, and larynx was very much congested. The spleen was so softened in its interior as to resemble the lees of wine.
This patient appears to have died rather from the want of admission of sufficient air to the lungs than from the effects of ether. The apparatus was applied without intermission, long after the face became injected, and was kept applied till it became of a violet colour. The pulse was not felt till the patient was dying. Artificial respiration was not attempted, although it would most likely have restored the patient.
The other death which happened whilst the patient was under the influence of ether took place at the Hotel Dieu de Lyons, on September 11th, 1852.[[166]] The patient was a woman, aged fifty-five, but looking much older. She was affected with a tumour of the superior maxillary bone, and was weak and in a bad state of general health. M. Barrier was reluctant to remove the tumour, but yielded to the entreaties of the patient. The ether was administered from a sponge placed in a bladder, and the patient was quickly put to sleep. M. Barrier had made the incisions in the face, and had just divided the ascending process of the jaw, when the breathing stopped. There was no pulse at the wrist, and it was doubtful whether there was any at the precordial region. The patient was placed horizontally, and artificial respiration and other measures were applied, but without success.
This patient evidently died of hæmorrhage; the mode of death which M. Barrier must have been dreading, as we perceive from his reluctance to perform the operation. According to the result of my experiments on animals, ether is not capable of causing the kind of death which this patient died.
There were three or four cases in which ether was blamed by the operating surgeons for causing the death of patients, who recovered from its effects, and, died some days, or at least hours, afterwards. The nature and circumstances of the operation were sufficient to account for the fatal result in each of these cases, whilst the extended use of ether has confirmed the opinion that it cannot be the cause of deaths which occur days, or even hours, after its use.
On Friday, the 12th of February, 1847, Mr. Roger Nunn performed lithotomy, in the Colchester Hospital, on a man who, as it was found after his death, had disease of the kidneys. The ether seemed to act favourably. Mr. Nunn says: “There was neither difficulty nor loss of time in cutting into the bladder; but having done so, some little delay occurred in grasping the stone, which was small, very flat, and lying in the posterior part of the bladder; the delay was also increased by the extremely relaxed state of the bladder itself, which seemed to fall in folds on the forceps, and to cover the stone.”[[167]] This delay in grasping the stone is attributed by Mr. Nunn to a collapsed state of the bladder caused by the ether, but it can only have arisen from the fact of the urine having escaped from the bladder, before the stone was seized. The small vessels divided in making the first incision showed much inclination to bleed, and Mr. Nunn secured them immediately after the patient was put to bed.
Speaking of his patient and the ether, Mr. Nunn says: “He recovered from its effects after a short time, and continued in a quiet passive state, but without decided reaction for twenty-four hours. At this period he had a chill, which lasted for nearly twenty minutes.” Stimulants were given, but without much effect. The patient seemed incoherent from eight o’clock P.M. of Saturday till nine A.M. of the following day. From this time he gradually sank, and died at five o’clock P.M. of that day, Sunday, being sensible to the last.
On March 9th, 1847, Mr. Wm. Robbs, of Grantham, removed an osteo-sarcomatous tumour from the back part of the left thigh of Ann Parkinson, a married woman, aged twenty-one, the mother of one child.[[168]] Mr. Robbs tried to make his patient insensible with ether, but did not succeed. He says, indeed, that in about ten minutes its usual effects were produced; but these could not have been its full and proper effects; for he says, “she appeared quite sensible to the pain during the whole of the operation.” It is reported that she appeared to feel the first cut. Mr. Robbs says that during the early part of the operation, the patient “cried out much, complained, and writhed in great agony of pain.” The operation was begun by an incision commencing midway between the tuberosity of the ischium and the trochanter major, and extending about six inches down the thigh. The fascia was next divided, and the muscles were next separated with the handle of the scalpel, so as to expose the upper surface of the tumour. After this had been done, the inhaler was replaced to the mouth of the patient whilst the operation proceeded, but the ether appeared to take no effect. The tumour was “very adherent to the long head of the biceps flexor cruris, which nearly covered it anteriorly, while posteriorly it rested on the sheath of the great sciatic nerve. It took its origin from the common tendon of the flexor muscles, close to the tuber ischii, and was inserted into the short head of the same muscle just below its origin.” Mr. Robbs says: “The dissection was protracted longer than I expected, from the violent contractions of the muscles, and the struggles of the patient.” He estimated the time occupied in the operation at twenty-five or thirty minutes; and the sister-in-law of the patient, who gave her evidence at the inquest, expressed her opinion that the operation lasted an hour all but five minutes. At the end of the operation, the patient appeared very faint, and the pulse was very rapid and feeble. The patient remained much depressed, with a pulse of 140 in the minute, small, and without much power, having her intellect perfect; she died forty hours after the operation.
A coroner’s inquest was held, but neither the coroner nor any of the jury appeared to have any knowledge or suspicion that a surgical operation on the thigh could possibly be the cause of death. A surgeon who gave evidence stated, that “the shock from the operation was not simply the cause of death, as the seat of the disease was not essential to life.” The verdict was, that the death of deceased was caused by the inhalation of ether; and that no blame was attached to the surgeon, as ether had been used and recommended by eminent medical men.
I cannot tell whether Mr. Robbs would have undertaken the operation if ether had not been about to be used, but if he had undertaken it without ether, one may presume that he would have done what every surgeon does who undertakes a great operation, that he would have informed the patient and her friends that it would be attended with some amount of danger. In his communication to the Medical Gazette, Mr. Robbs complains of the friends of his patient having thought it necessary to obtain a coroner’s inquest; but he has himself to blame for that. After he had attributed the death entirely to a new agent, which had been given with a view to prevent the pain, and had entirely failed even in that, it was very natural that they should seek for a legal investigation of the affair.
Mr. Robbs makes no admission that the pain his patient suffered could be due to any defect in the administration of the ether. He states, that he “was quite unprepared for that perfect state of prostration of the brain and nervous system which it appears in this case to have induced”. The fact of the patient crying much, and complaining, and writhing in great agony of pain, and the contraction of the muscles, and the struggles which protracted the operation, do not look like a prostration of the brain and nervous system. At the end of the operation she was, to be sure, prostrated by its long duration, and the great loss of blood which must have occurred; but her brain and nervous system were not so much affected as the vascular and muscular system. She spoke of the operation as having been very severe, and she retained her mental faculties perfectly to her death. Ever since 1818 many of the students at lectures on chemistry had inhaled the vapour of ether to quite as great an extent as Mr. Robbs’ patient.
As a proof how far the feelings will suspend both reason and common sense, it may be mentioned that some of the medical men, who were strongly opposing the use of ether in 1847, did not hesitate to allude to the inquest in this case, as showing that ether had caused the death of a patient.
Mr. Eastment, of Wincanton, Somersetshire, related a case[[169]] in which he attributed the death of the patient to ether. It was apparently the first time he had seen ether employed on the human subject; and with a larger experience of its effects, he would no doubt alter his opinion respecting the cause of death in the case he related.
A boy, aged eleven years, became entangled in the machinery of a mill, about eight A.M., on February 23rd, 1847, in consequence of which he sustained a very severe compound fracture of the left thigh, with great laceration of the soft parts, and a simple fracture of the right thigh. The surgeons in attendance waited till four P.M. for the boy to recover from the shock of the injury, and then performed amputation of the left thigh. Ether was given, but so badly, that the patient’s sufferings were so severe on the circular incision being made, that it appeared to be a complete failure. The inhalation was repeated, however, and the pain of the latter part of the operation was prevented. The patient died three hours after the operation, being in a state of great exhaustion, with occasional mental excitement, during the three hours.
This patient’s chance of life would probably have been improved if the ether had been more effectually given, so as to prevent all the pain of the operation; but I believe that his chance of recovery would have been most improved by administering the ether soon after the accident in the morning, which would most likely have removed the collapse, and enabled the surgeon to perform amputation at once, and thus have prevented the eight hours suffering and depressing effects of the great laceration of the thigh.
M. Bouisson[[170]] has mentioned a case in which death was attributed to ether by a surgeon named Roël, of Madrid. Dolorès Lopes, aged fifty, of very feeble constitution, and addicted to drunkenness, had long suffered from a cancerous tumour of the breast. It was removed after the patient had inhaled ether for half an hour, and it weighed three pounds and a quarter. The patient died seven hours after the operation. But the operation itself was sufficient to account for the death of such a patient; and she could not die from ether at the end of seven hours after inhaling it.
On account of its great safety, ether is extremely well adapted for medical cases, in which it is necessary that a narcotic vapour should be administered by the patient’s nurse.
The Combination of Chloroform and Ether. Some practitioners have recommended the inhalation of the vapour from a mixture of chloroform and ether; but the result is a combination of the undesirable qualities of both agents, without any compensating advantage. Ether is about six times as volatile as chloroform—that is to say, if equal measures of each be placed in two evaporating dishes kept side by side, at the same temperature, the ether evaporates in about one-sixth the time of the chloroform; and when the two liquids are mixed, although they then evaporate together, the ether is converted into vapour much more rapidly; and, in whatever proportions they are combined, before the whole is evaporated the last portion of the liquid is nearly all chloroform: the consequence is that at the commencement of the inhalation the vapour inspired is chiefly ether, and towards the end nearly all chloroform: the patient experiencing the stronger pungency of ether when it is most objectionable, and inhaling the more powerful vapour at the conclusion, when there is the most need to proceed cautiously.
A death which occurred during a surgical operation in America, has been attributed to the mixture of chloroform and ether which was employed;[[171]] but there is no doubt that the patient died of hæmorrhage. Dr. R Crockett, of Wytheville, Virginia, removed a fatty tumour from the back of a boy, aged five years. Four parts of washed ether by measure were mixed with one part by measure of chloroform, and a drachm of this mixture was poured on a funnel-shaped sponge which was applied near the mouth and nostrils. The tumour was very large, and required two incisions of nine inches in length for its removal. Six arteries required to be tied; and just as the last one was secured, the child began to vomit. He was found to be pulseless, and he died three or four minutes from the commencement of vomiting. Dr. Kincannon, who was present, and watching the patient, said that up to the time he began to vomit, there was nothing in the circulation or respiration to produce the least apprehension.
The operator said that the patient probably lost four ounces of blood, certainly not six. It must be observed that as the blood during an operation is carried away by the sponges, it is impossible to estimate the amount. It could be ascertained only by an analysis of the water in which the sponges are washed. But even admitting that in the present case the loss of blood did not exceed six ounces, it is probable that this amount, flowing suddenly from a child of five years of age, might cause death. Vomiting does not take place when a patient is deeply under the influence of ether or chloroform, and the fact of no signs of over narcotism having appeared, confirms the view that death was occasioned by the loss of blood.